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ICICI LOMBARD GENERAL INSURANCE COMPANY

IRDA Registraion No.115
MOTOR INSURANCE PROPOSAL FORM
PRIVATE CAR  PACKAGE POLICY
Proposal Form No: 2626806919

Registration Address (Where vehicle is

registered): My Occupation Details
Main Features:
Room No. / Block No. / House No.: H No- Status Individual Proprietorship
I. Own Damage 101/12, Mohar Singh Chowk Kalandar Chowk Partnership Pvt / Public Co's
This product Protects you Against loss or Building Name/ Wing/ Plot/ Other(pl. specify)
 damage to your motor vehicle and/or Sector No./Floor No.:
 accessories due to Occupation:
Road No./ Street Name: Panipat
Land Mark: If Entity Urban Rural Social
•fire •selfignition •explosion Business Paid up Capital of Company in
•lightning •theft •burglary Area/ Village:
Rupees
•housebreaking City/ Town: Panipat
State: Haryana <10 Crore 10-25 Crore >25
•riot •strike •earthquake •flood &
Crore
allied perils •accidental external means Pin Code: 132103
•malicious acts •terrorist activity Country: INDIA Category of Business Trading
•transit •landslide •rockslide Manufacturig Contracting
Correspondence Address Hospitality Financial Services
II. Third Party Liability
Room No. / Block No. / House No. Other(pl. Specify)
In addition to the coverage noted above,
this ______________________________________ Annual Income :
 product covers you against legal liability Building Name/ Wing/ Plot/ Sector No./Floor Do you file Income Tax Return Yes
towards No. : No
 third party, in respect of the following: Road No./ Street Name:
Do you own a Bank Account Yes
Land Mark
Death of bodily injury to any No
City/Town
person.
Damage to property as per the State Section II
provisions of Motor vehicle Act. HARYANA
We are pleased to inform you that Pin Code My Vehicle Details
in addition, the product also 132103 Date Of Purchase: 13/07/2022
include the following: Country : Date Of Registration: 13/07/2022
Personal accident benefits for INDIA Registration Number: HR06BA9861
ownwer driver upto value of Preferred Mailing Registration Authority: HARYANA-
Rs.2,00,000/ Rs. 1,00,000 (For Address Registration Correspondence PANIPAT
Two Wheeler).
If Corporate, vehicle used by: Mr./Ms.: Year of Manufacture: 2022
Legal Liability towards the paid
driver. Phone(with STD Code:(R)   Country of Mfr.
Cover of Rs. 7.5 Lacs and Rs.1 Mobile No.: 9996618518 _______________________
Lac(for Two Wheelers) for third Fax No. :_____________________________ Engine Number: G4LANM181908
party PropertyDamage Email Id: [email protected] Chasis number:
Date Of Birth: 01/01/1999 MALFB81BLNM342868
Significant Exclusion Make of Vehicle: HYUNDAI
Sex   M F
Model: VENUE 1.2 S
We would like you to know that the Marital Status:
Cubic capacity/    1197
policy does not cover consequential loss  Professional Qualification : Doctor gross vehicle weight:  1
depreciation, normal wear and tear,
MBA Engineer Type Of Body: SUV
mechanical or electrical breakdown
failures or breakages. The vehicle is not Lawyer Architect CA Seating Capacity: 5
held covered if used for commercial Journalist IT Student Carrying Capacity: 4
purposes or if driven by an unauthorized Graduate Post Graduate Other(pl. Fuel Type : Diesel Petrol CNG
driver. Specify) LPG Hybrid
Note: The foregoing is only an indicaton
of the cover offered. For details please Colour Of Vehicle :
refer to the policy. It is our endeavour to Colour Finish : Metallic Non-
provide consistent quality service to all Metallic
our customers. To enable us to deliver our Whether the vehicle is driven by
promise, we would appreciate if you non- conventional source of power/CNG
would take some of your time to answer
/LPG /Bi-Fuel? Yes No
all questions fully and correctly to the
If Yes, Please give details whether the use
extent possible. We would like to let you
of vehicle is limited to own premises?
know that insurance is a contract of
Utmost Good Faith requiring the Yes No

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customer to disclose all material facts Whether the use of vehicle is
without suppressing any vital information used for commercial purpose? Yes
whether material or otherwise. If in your
No
opinion any fact is material and is not
covered by the Information sought in the   Whether the vehicle is used for driving
application form, we request you to tutions?
disclose it. It is important to note that the   Yes No
liability will commence only after we
have accepted yous proposal and the
premium has been received in full.

Section I

Personal Details

Name: Mr/Ms./M/s.: MAHESH

NAGPAL

GSTIN Reg. No. Customer :

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Vehicle Proposed for Insurance Personal Accident cover for Owner Driver is (If yes, reasons there
under hire purchase lease compulsory for__________________________)
in the Liability Only Cover. C)Imposed special Condition or
agreement under hypothecation
Please give details of nomination: excess: Yes No
none of above a)Name of the Nominee &  0
In case the proposed vehicle is under Age:  Declaration: We further undertake
hire purchase/lease agreement /
b)Relationship: that if this declaration is found to be
hypothecation, please provide
c)Name of Appointee (If  0 incorrect, all benefits under the
following details of the parties having
Nominee is a Minor): policy in respect of Section I of the
a financial interest in the Vehicle (s)
d) Relationship to the Policy will stand forfeited. Me, the
Name of the party: NA
Nominee: undersigned hereby declare that the
Address of the party:
above statements and particulars are
Vehicle's Insurance Coverage If Yes , give name and Capital Sum Insured(CSI) opted true, accurate and complete and
Details for: IAVe declare that this declaration
and the answer given above shall be
Name CSI Nominee Relationship
Period of Insurance: Time :Midnight held to promissory and shall be the
Opted
of 03/08/2023 17:23 TO Midnight of basis of the contract between me/us
(Rs.)
02/08/2024 23:59:59 and ICICI Lombard. The policy
1)       may however be continued at the
Coverage required for: PVT Car 0 sole discretion of ICICI Lombard.
Two wheeler PCV 2)       subject to payment of the amount
GVC Misc 3)       payable as determined by ICICI
Insured Declared value of Vehicle Lombard. resulting from the
(Provide bifurcation of body difference in the bonus / malus
&chassis value, if applicable): Do you wish to include Personal Accident cover for status. I shall endeavor to procure
Un-named Passenger/hire/pillion passengers (Two the renewal notice and pass on the
Body price:
same to ICICI Lombard
Chassis price: Wheelers)? Yes No
immediately upon the receipt of
Value of non electrical accessories, if such notice. I /We declare that the
any If Yes, Give number of persons and Capital Sum Isured
rate of NCB claimed by me/us is
(Please attach bills): Rs. 744200 (CSI)
correct and that no claim as arisen
Opted.rblCovforConsmblItemsrblCovforConsmblItems
in the expiring policy period (copy
Value of electrical/electronic No. of Persons:C.S.I(Per Person):
of the policy enclosed). I/We
accessories if any (Please attach Whether extension of geographical area to the
further undertake that if this
bills): folllowing countries required?
declaration is found to be incorrect
Rs. Bangladesh Bhutan Maldives Nepal all benefits under the policy in
Pakistan Sri Lanka respect of Section I of the Policy
Value of non conventional source of
will stand forfeited.
power (CNG/LPG) if any: Rs.  /
COMPULSARY PERSONAL ACCIDENT Place : _________________
Rs.
COVER FOR OWNER DRIVER Date: |__|__|/|__|__|/|__|__|__|__|
Value of Trailer, if any: Do you have a Valid Driving Licence Yes No
Rs. Do you have own Mutiple Vehicles Yes No
____________________
Trailer Chassis No.:   PAN of POS.:
Signature of Proposer
Total Value: Rs. _________________
Whether extension of geographical OTHER INFORMATION
area to the folowing countries Vehicle's Insurance history
required? Name and Address of   IFFCO TOKIO
At the time of Purchase the vehicle
Previous Insurer: HARYANA
Bangladesh Bhutan was:   New Secondhand
Previous Policy Type: Liability only Cover
Maldives Nepal Pakistan Will the vehicle be used
Package Cover Others
Sri Lanka exclusively for private,
Previous Policy No.: 55115302
Whether the vehicle is fitted with social, domestic,pleasure &
Period of Insurance: 6/27/2022 12:00:00 AM  -
fibre glass tank? professional
6/26/2023 12:00:00 AM
Yes No Existing bonus/ malus status: % puroses: Yes No
  (Please attach a copy of last policy/renewal notice Will the vehicle be used for
held) carriage of goods other
Liabilty To Third Parties
In the last three years. Is there any history of loss than samples or personal lugguage:
Coverage for liability against Third
Experinced by the proposer(s) or other drivers who Yes No
Party risks (Death or Bodily Injury)
required in respect of: would by using this vehicle Yes No The vehicle is in good condition:
If Yes, deails are: Yes No
i) Owner Driver only Yes No
Date and time Name of the Nature of loss Ammount
ii) Any person other than Paid The vehicle is self owned: Yes
of loss driver at the Claimed
Driver Yes No timem of loss (Rs.) No
If Yes, Give details of such other         The vehicle belongs to foreign
persons:         embassy consulate? Yes No
1.____________________________
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2.____________________________         The car is certified as Vintage car
3.____________________________     by Vintage and
Do you wish to have the statutory Has any Insurance company ever: Classic Car Club of India: Yes
Third party A)Declined the proposal: Yes No No
Property Damage (TPPD) liability
B) Cancelled/ refused to renew Yes No The vehicle is designed for use of
of Rs. 6000/- only? Yes No Blind/Handicapped/mentally
The policy provides additional Third challenged persons
Party and duly endorsed  as such by
Property Damage liability limits of RTA: Yes No
Rs. 1,00,000/-
The vehicle is chauffeur driven:
for Two Wheelers and Rs.7,50,000/-
for other Yes No
Classes of Vehicles. Do you wish to Are you a member of Automobile
cover the Association of India: Yes
additional limit? Yes No No
Legal liability to person employed If Yes: 
in connection with operation of the         
vehicle who are workmen. Is the vehicle fitted wth the any
i) Drivers(No. of persons):  1 Anti-theft device
ii)Employees (Workmen) (No. of approved by the AARI: Yes
persons ): 0 No
iii)Cleaner/Conductor (No. of Do you wish to avail a voluntary
persons):  Excess?:
iv)Non-Fare paying passenger(No.
Yes No
of persons): 
If Yes, Please indicate your choice:
 Do you wish to cover wider legal
liablity to Rs.2,500 Rs.5,000
employees who are workmen? Rs.7,500 Rs.15,000
Yes No Is the vehicle owned / hired /
leased / permitted by the state ?
 Do you wish to cover wider legal
liablity to Yes No
employees who are NOT workmen?  
YES NO

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Driver's Details I/We hereby declare and warrant that the

Motor Related Addon Covers Details of Driver above statements are true, accurate and
a. Age & Date of Birth of the Owner: complete. l/We
1.Do you wish to include Cover for Zero  desire to effect an insurance as described
Age______Yrs
Depreciation: Yes No DOB:|__|__|/|__|__|/|__|__|__|__| herein
2. Do you wish to include Cover for  with the Company and l/We agree that
b. Age & Date of birth of the Driver:
this
Consumable Items: Yes No Age______Yrs  proposal and declarations shall be the
3. Do you wish to include Cover for DOB:|__|__|/|__|__|/|__|__|__|__| basis of
Return to Invoice Add-on: Yes No c. Does the driver suffer from defective contract between me/us and the Company
If Yes, please indicate Registraion + Road vision or hearing or any physical and
Tax Charges Paid  infirmity:  I/We agree to accept a policy subjet to the
4. Do you wish to include Cover for NCB _________________________________  conditions prescribed by the Company.
d. Has the driver ever been involved/ I/We
Protect Add-on: Yes No  
convicted for causing any accident of  hereby declare and undertake that the
If yes, please indicate the plan chosen
Number of claims to be considered loss?    Yes No amount
eligible for this add-on 0 If Yes, give details as under including the  paid by me/us as premium for the
pending prosecutions: aforementioned
5.Do you wish to include Cover for
-Driver's Name:  policy is out of my/our lawful and
Garage Cash Add-on: Yes No declared source
If Yes, Please indicate -Date of Accident:
 of income.
a) The Daily Allowance Opted for : 0 -Loss/Cost(Rs.):  I hold a valid and effective PUC and/or
b) The maximum Coverage Days opted -Circumstances of 2626806919 fitness certificate,
for : Accident/Loss:  as applicable, for the vehicle mentioned
c) Maximum amount payable in the herein and undertake
event of the claim under this add-on: Declaration  to renew the same during the policy
I/We hereby declare that the statements period.
d) The minimum number of days in
made by me/us in this Proposal Form are
excess of which the claim will be
true to the best of my/our knowledge and Subject to realisation of cheque
payable from the day such vehicle was
belief and I/We here by agree that this
delivered to the garage for   :  Place:__________________________
declaration shall form the basic of the
6. Do you wish to include cover for Road contract between me/us and the "ICICI Date: |__|__|/|__|__|/|__|__|__|__|
side assistance: Yes No Lombard General Insurance Col. Ltd."
If Yes, Please provide you residence I/We also declare that any additions or
address: Arrangement of keys,Towing on alterations are carried out after the
Statutory Warning
breakdown/accident upto 50 submission of this proposal from then the
km,Arrangement/Supply of same would be conveyed to the insurers PROHIBITION OF REBATES
fuel,Arrangement of rental immediately. I agree that the Policy shall Under Section 41 of Insurance Law
vehicle,Battery jump start,Arrangement become voidable at the option of the Amendment Act 2015
of Accommodation,Flat Tyre Insurer, in the event of any untrue or
support,Minor on spot incorrect statement, misrepresentation, No person shall allow or offer to allow,
Repairs,Breakdown support over phone nondescription or non-disclosure in any either directly or indirectly as an
Name of the emergency service selected material particular in the proposal inducement to any person to take out or
are as below: form/personal statement, declaration and renew or continue an insurance in respect
7. Do yopu wish to include Cover for connected documents, or any material of any kind of risk relating to lives or
information has been with held by me or property in India, any rebate of the whole
Engine Protect Plus: Yes No
anyone acting my behalf to obtain any or part of the commission payable or any
8.Do you wish to include Cover for Tyre benefit under this policy. I affirm and rebate of the premium shown on the
Protect: undertake that I have read and understood policy, nor shall any person taking out or
Yes No the policy wordings, terms & conditions renewing or continuing a policy accept
9. Do ou wish to include Cover for Loss and exclusions governing the cover and any rebate except such rebate as may be
of Personal Belongings: agree to abide by them. I agree to receive allowed in accordance with the published
Yes No a One Page Motor Insurance Policy in prospectuses or tables of the insurer. Any
Physical Form Yes No By agreeing to this, person making default in complying with
If yes please indicate the plan chosen
I understand that the same shall be read the provisions of this section shall be
.Sum Insured Rs. 50000
along the standard terms and conditions liable for a penalty, which may extend to
10. Do you wish to include Cover for
available on the website ten lakhs rupees. Table1: This section shall
Key Protect Add-on: Yes No (www.icicilombard.com) be liable for a penalty, which may extend
If yes, please indicate the sum insured to ten lakhs rupees. Table 1: Schedule of
amount depreciation of arriving at IDV. The
50000 Insured value (IDV) of the vehicle will be
deemed to be the 'Sum Insured'
IDV CALCULATION
AGE OF THE DEPRECIATION
VEHICLE
Upto 6 Months 5% 5%
6Months 1day to 15%
1Year 15%

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1Year 1Day to 20%

2Years 20%
2Years 1Day to 30%
3Years 30%
3Years 1Day to 40%
4Years 40%
4Years 1Day to 50%
5Years 50%
NOTE: IDV of vehicles beyond 5 years
of age and obsolete models o the vehicles
(i.e. models which the manufacturers have
discontinue to manufacture) is to be
determined on the basis of the
understanding between insurer and the
insured.

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